malaysiakini: 1Care: Unhealthy lack of public engagement... by Dr Helmy Haja Mydin

1Care: Unhealthy lack of public engagement

Dr Helmy Haja Mydin
May 20, 2011, 1:05pm

 

 

One of the essential features of a successful healthcare system is the presence of a well-organised primary care service that provides comprehensive services to the public that it serves.

Primary care services are usually delivered by a general practitioner(GP) and should ideally deal with a wide range of healthcare issues, from dealing with minor acute ailments to keeping a lid on the development of chronic illnesses.

In Malaysia, we tend to only visit our GPs if we are plagued by a sore throat or any other common acute illnesses. We also have a tendency to move around and not stick to a single practitioner; we tend to be satisfied as long as the costs are covered by a 'panel doctor' that is recognised by our insurance company or employer.

This is obviously disadvantageous, as a key characteristic of primary care is continuity - the GP is meant to act as the gatekeeper to secondary care services, and also plays the role of the family physician.

There is reason to believe that the Ministry of Health has plans to reconfigure the primary care landscape. There will be focus on a number of areas, namely policy development and program direction, comprehensive primary care services and benefit packages, quality assurance and performance indicators and last, but not least, human resource development and training.

With the latter issue, it is worth noting that there are less than 400 qualified GPs who are registered with the National Specialty Register, with another approximately 8,000 practitioners who will need to be trained in a recognised postgraduate course.

This contrasts with the situation in the United Kingdom, where primary care services are provided by around 36,000 GPs in approximately 8,200 practices for a population that is roughly double that of Malaysia.

These GPs carry out over 300 million patient consultations a year, and play a significant role in not only improving the lives of their patients, but also ensure that financial and human resources for secondary and tertiary services are not overwhelmed.

An integrated service would also be beneficial in helping identify areas of medicine for which more emphasis should be given or those that could be improved upon. It would also prove to be an invaluable research tool, one that will allow us to target our population appropriately, as we have a unique ethnic mix that is not replicable elsewhere in the world.

It is understandable that the government intends to restructure of our healthcare system and it will be laudable should they devolve power to the periphery. By transferring authority and emphasising the greater role of primary care, the centre of decision-making is shifted towards that of the patient, who is ultimately the main stakeholder in any shift in healthcare provision.

Unfortunately, negotiations are currently being made behind closed doors without any engagement with the public.

In tandem with this conversation, we should also place more efforts on the education of the public, as most users of the Malaysian healthcare service are not aware of their rights and access to healthcare, nor of the important role of primary care.

There is also a troubling lack of emphasis in highlighting issues pertaining to healthcare issues, as evidenced by the lack of constructive debates regarding healthcare policies.

It is therefore our hope that the government will be more forthcoming with regards to the upcoming changes in our healthcare system. For too long we have allowed our primary care services to languish in the shadows. With sufficient public support and political will, the necessary changes made will lead to a more comprehensive and accessible service for all of the rakyat.

Dr Helmy Haja Mydin is a fellow at the Institute for Democracy and Economic Affairs

The Guardian: NHS reform: The GPs on the 'dark side'

NHS reform: The GPs on the 'dark side'

The government wants to put GPs in charge of NHS budgets to improve treatment. In Cumbria, they're already doing it. Sharon Brennan went to find out how it's working

• Sharon Brennan
• The Guardian, Wednesday 5 January 2011
•  

'People view me as being part of the dark side. They think it’s about saving money,' says Peter Weaving, GP (above). Photograph: Christopher Thomond for the Guardian

Rachel Robinson, 78, struggles to the door, walking stick in hand, to answer my knock. She has been "cut off" from her local community in Brampton, Cumbria, these last few months due to painful sciatica. She is now waiting for an MRI scan at Carlisle hospital, a scan that her local GP, Peter Weaving, was able to directly book for her. It is a small change that hides a radical shift in NHS power in the county. "Weaving's personal relationship to me is invaluable," says Robinson, and it is this powerful bond between GP and patient that the government is keen to harness and emulate nationwide.

In April last year, Cumbria's primary care trust (PCT) transferred its budget management powers to its GPs, enabling them to commission their patients' care. It is a move that closely echoes the government's ambitious plans for the NHS.

By 1 April 2013, the health secretary, Andrew Lansley, intends to eradicate PCTs and hand up to £80bn of the NHS budget to consortia of GPs across England to spend on commissioning the vast majority of NHS services, including maternity, mental health and accident and emergency hospital departments. In response to the health white paper consultation, the government last month said it intends to "press ahead immediately with pathfinders of GP consortia".

In 2006, Cumbria was in a "very bad place" according to Sue Page, 52, who had moved that year from heading Northumbria Healthcare NHS trust to become chief executive of NHS Cumbria. "There was an amazing amount of clinical disengagement and we had historic debt rising up to £36.7m," she explains.

In a bid to find a solution to years of overspending, Page introduced a Care Closer to Home strategy, designed to give Cumbrians a local health service that suited them while simultaneously balancing the PCT's books.

Page was to achieve this by putting the "docs in charge" of their budgets. Her rationale was that GPs, who are responsible for 90% of the public's contact with the NHS, were best placed to make difficult monetary decisions over treatment.

Four years on, this decision has seen 70% of the area's budget devolved to the doctors' control. This will rise to 97% by April. GPs are in charge of managing the budget for all prescription costs, running GP surgeries, commissioning services from local hospitals and budgeting for new local care plans, such as community nurses.

It is this concentration of power in primary care providers that has enabled Robinson to bypass a hospital consultation, the normal route to receive an MRI scan, significantly reducing her waiting time. According to Weaving, it is these "trivial things" that doctors have "waited years for" that will win them round to accepting budget responsibility.

Weaving, a senior partner at Brampton Medical Practice, is also one of six "lead GPs" who are each responsible for heading the GPs in the region within which they are based. These six come together in a formalised committee – the Clinical Senate – to debate commissioning issues that affect the wider county. Weaving works three days a week as a GP, dedicating the other two days to commissioning care in Carlisle, his region, or sub-locality as it is officially termed.

He admits it took "a lot of one-to-one conversations" to convince other doctors of his motives. "People view me as being part of the dark side. They think it's about saving money," he says. Although every Carlisle GP is part of his sub-locality, "probably about 10% or less are card-carrying enthusiasts", Weaver says, which means he has to step in to manage a practice's budget if it is not ready to do so.

Chris Corrigan, a partner at Brunswick House Medical Group in Carlisle, was one of those doctors who resisted the changes. For more than a year he was adamant he would not be involved in any scheme focused on reducing hospital referrals for budgetary reasons alone, but he was eventually won round to the scheme through the "credibility" of Page's leadership. "She proved her worth, she seemed pretty brave and prepared to take risks where other people were not," says Corrigan.

He is now involved in commissioning, leading a group of GPs to implement National Institute for Health and Clinical Excellence recommendations on hospital referrals, but remains clear that his "prime responsibility" is to act as his patients' advocate.

He questions whether GPs nationwide will be "responsible" with budgets that are at risk of an overspend, such is the strength of feeling for putting a patient's interests first.

Dan Golding, a partner at Nutwood surgery, Grange-over-Sands, shares Corrigan's concerns. Describing himself as a "coalface" GP, Golding has played no part in the Cumbrian reforms other than opting in to one of the county's six sub-localities. "I have some reservations. Say we get to this point in the year and there is no money left, where does the buck stop?

"I wouldn't be happy telling someone they can't have their hernia operation because there was no cash."

Evolutionary approach

Initially it was Page who championed clinical leadership, asking GPs such as Weaving with experience in managing budgets to "join the gang" in the early stages of implementation. Page admits that she would push doctors to take control but believes the process had "to come from the ground up", with the six localities taking shape from conversations on the street corner. "So over the four-year period, the gang of six became a gang of 20 became a gang of 50 and so on." She credits this evolutionary approach as the reason why there is only one practice in Cumbria opting out of the reforms.

The success that Cumbria has had with its commissioning model has instilled doubts among some of the region's doctors over Lansley's approach. He intends to compel GPs into taking up commissioning by refusing patient lists to those who do not comply. But Corrigan is unconvinced that enforcement will work, arguing that peer pressure is a more effective way forward. Following Cumbria's example, he believes it is "more crucial to identify lead GPs who are respected locally and to give them a position of authority."

Paul Corrigan, author of a Demos thinktank paper on the Cumbrian reforms, believes that the government's April deadline for all GPs to start commissioning services is a big problem. "As we get closer to that date there will be areas of the country that will not be ready and the government will then have to decide whether to extend [the deadline] or say to parts of the country, two years before a general election, we will make them do this even though they aren't going to do it very well," he says. He believes that Cumbria's reforms are comprehensive and have driven real improvements in patient services but credits the "very high-class local GP leadership" and the "time and effort [that] goes into helping those leaders to develop".

Weaving believes that "hard outcomes" are the best way of convincing unenthusiastic GPs that the new commissioning model works. In the 2009 transition year, when doctors made the decisions but the PCT approved the budget, Cumbrian GPs started offering minor hand operations from their surgeries at 20% less than the cost at hospitals. GPs are now in the process of introducing angioplasty operations in local hospitals that would allow Cumbrians to receive a single treatment immediately after they have had a heart attack. At present such patients have two less effective staggered treatments at a higher cost because they cannot reach fast enough the Newcastle hospital that offers angioplasty.

As Cumbrian GPs have placed their emphasis on providing primary care in their surgeries, hospital procedures have reduced. In Cumbria, the hospital's emergency admissions budget has been cut by 6%, a reduction of £6m in a single financial year, reflecting the fact that better community care is stabilising many patients with long-term illnesses.

Weaving admits that downsizing Cumbrian hospitals will be a "very sensitive thing for the public", but resources have been redeployed into creating new community NHS services as a result, such as setting up a team of home care nurses, with £6m of extra investment in 2009. He argues secondary care is often the "kneejerk response" for many GPs. "We were relying on a lot of overuse of our hospital bed base which was the most expensive healthcare. That is fine if you need it but doctors should regard it as a very scarce resource," he says.

Lack motivation

The British Medical Association has raised concerns that GPs will lack motivation if they are unable to improve patient care as a result of being burdened with current PCT debt. Chris Corrigan says it was Page's ability to get the strategic health authority to write off three-quarters of Cumbria's historic debt that won her the respect of the region's medics. As Golding puts it: "I'm much more likely to play ball if there is a carrot in it for me, but, more important, my patients". The government says consortia "will not be responsible for resolving PCT legacy debt that arose prior to 2011/12" but debt accrued after this period will be the GPs' liability when they take the reins in 2013.

Cumbria does not yet have all the answers, but the question is whether the government's plans for GP commissioning will make a real difference. "There are two ways this will go," says Chris Corrigan. "One is it will be very, very different to PCTs and it will work in 60% of the country and not in the rest. Or it will be very similar to PCTs in which case they would have gone through an enormous set of changes with no real difference".

Robinson is relieved that her painful condition may be resolved more quickly due to the commissioning reforms in Cumbria, but she remains pragmatic about the wider forthcoming NHS funding changes. "In a way it's all of our problems. We expect so much in terms of treatment and what is available and I know very well that it is not a bottomless pit."

NST: DG says: 'Future of GPs assured'

'Future of GPs assured'

NST: 2010/12/05

GENERAL practitioners will not be marginalised or made irrelevant with the introduction of the primary healthcare-led (PHC) reform under the "1Care for 1Malaysia" programme.
This assurance comes from director-general of Health Tan Sri Dr Ismail Merican who stressed that the future of GPs was "secure" under the proposed restructuring of the healthcare system.

Dr Ismail said the 1Care for 1Malaysia reform was necessary as sustaining the present healthcare system would be difficult in the face of a changing environment with double-disease burden, changing disease patterns, increasing healthcare costs and increasing demands by a more informed population.

"The need for change is inevitable. There are early signs of deterioration in the service delivery. The out-of-pocket expenditure in healthcare has escalated.

"There is widening disconnect between the public and private sectors and primary and secondary care, which will compromise the continuity and comprehensiveness of care and create an additional burden to the public."

To meet these challenges, he said the country would need about 17,000 to 23,000 doctors to be trained as primary health care physicians in the next 10 years.

He urged GPs and family medicine specialists in the public sector to join forces to provide comprehensive primary healthcare.

"For this to happen, GPs must enrol in courses to upgrade their skills and knowledge, and they can do this online without having to vacate their offices or clinics.

"The government, through the Ministry of Health, is prepared to even provide some funding for them to do so."

He explained that the 1Care for 1Malaysia programme would also change the way healthcare is financed and delivered by moving away from the current fee for service, volume-based system to one that is based on value and performance.

He said the fear by GPs that this represented a "diminishing pie" or a "shrinking income" for them may be misplaced.

"The details are still being worked out and we seek the views of GPs before any final decision is made."

Read more: 'Future of GPs assured' http://www.nst.com.my/nst/articles/05spd2/Article/#ixzz17DAAggrJ

GPs: Some are making only RM10,000 a month.... New Sunday Times

Some are making only RM10,000 a month

New Sunday Times, 5 Dec 2010

OPERATING your own medical clinic is not as attractive a career option as it was some 10 years ago, as about 80 per cent of general practitioners in the country are now merely "eking out" a living. 

"From the feedback we have received, it is estimated that some 10 to 15 per cent of the 8,000 GPs in the country are doing poorly.

"The bulk are eking out a living, earning less than RM10,000 a month, which is not much when one considers the years they have put in in medical school and the cost of medical education," says Malaysian Medical Association (MMA) president Dr David Quek.

A recent primary care research study undertaken by the MMA revealed that the solo GP is now faring the worst, with take-home earnings of sometimes less than a few thousand ringgit a month after taxes, clinic rentals, expenses and other payroll.

"Those who only work as locums fare even worse, sometimes earning less than RM5,000 per month from long hours and plenty of night calls."

He says the average income of the GP has been steadily declining, "although one can find the odd very successful GP".

The problem is largely because many GPs choose to set up practice in an already concentrated urban area.

"Sometimes there are three to four clinics in a single row of shoplots. The rising cost of rentals and in hiring clinic assistants and workers has also contributed to higher overheads.

"And because it is so competitive, many do not charge their professional fees to keep the cost to the patients low in the hope of attracting more patients," he adds.

The problem is also attributed to the stringent requirements of the Private Healthcare Facilities and Services Act 1998.

"The regulations have made the practices harder because of more inspections and compliance issues which GPs sometimes find hard to fulfil."

Added to this, he says, is the competition from unscrupulous community pharmacies and certain pathology laboratories, which dish out medications without prescriptions, or offer simplistic point of care.

"All these bite into the shrunken cake."

Dr Quek believes the fate of existing GPs will be further threatened with the Ministry of Health's expectation of having some 85,000 doctors by 2020, to meet the 1:400 doctor-patient ratio.

"We agree that it would be ideal to achieve this doctor-patient ratio in the future, but to forcibly push this at such an unprecedented rate is foolhardy. We believe this rate is too fast, too soon."

He says it is unrealistic for the ministry to expect to retain some 50,000 doctors in the public sector as even with expanded facilities and positions, it would not stop these doctors from leaving the public sector for the more independent private sector.

What is more regrettable, Dr Quek adds, is that there is a tendency for the ministry officials to suspect that the GPs and private sector doctors are not offering good enough care.

"There is this prevalent feeling that GPs are not good enough and have done too little to improve the standards of their practice, although there is no data to prove this. This is highly contentious and probably way off the mark."

He says it's ironic that the ministry should feel this way considering that all GPs in the country "graduated" from the public system through at least three years of compulsory service.

"Perhaps this speaks volumes for the 'failed' approach in 'training' or utilising our medical officers that they should still be considered inadequate after five to six years of medical school, three to four years of supervised housemanship and even mandatory medical officership."

The National Health and Morbidity Survey 2006 showed that 62 per cent of all outpatients sought care from the private sector and this was testimony to the quality of care that GPs provide.

"Thus, our GPs must be doing something right. They offer about the most cost-effective quality and moderately priced healthcare available in the region," he says, stressing that most GPs look after generations of families.

There is also a growing fear among the GPs that they will be marginalised with the implementation of the "1Care for 1Malaysia" health reform and integration of the public-private sector which will see the family medicine specialist serving as hands-on first providers as well as gatekeepers in the revamped primary-care led referral system.

The MMA says this would put GPs at a severe disadvantage or even discriminated against as not many would be able to realistically upgrade themselves into "family medicine specialists".

Dr Quek says GPs need to engage in continuing professional development to keep up with new knowledge and skills.


Read more: Some are making only RM10,000 a month http://www.nst.com.my/nst/articles/05spd1/Article#ixzz17D8ak6y1

The Guardian: Doctors warned to expect unrest over NHS reforms... by Dennis Campbell

Doctors warned to expect unrest over NHS reforms

Exclusive: GPs' leader criticises Lansley's reform plans and predicts that doctors will face demonstrations by angry patients  

by Denis Campbell, health correspondent 

guardian.co.uk, Friday 19 November 2010 21.02 GMT

 

Clare Gerada, chairman of the Royal College of GPs. She predicts trouble for doctors from a public angry at Conservative NHS reforms. Photograph: Frank Baron for the Guardian

Doctors face demonstrations outside their surgeries and questions about their high salaries by angry patients because of the government’s radical NHS shakeup, the new leader of Britain’s GPs warns.   

Desperate patients denied life-extending drugs or surgery for their ailments may also vent their frustrations on GPs, because they are due to assume control of deciding how £80bn-a-year of health funding is spent, said Dr Clare Gerada, who takes over tomorrow as chair of the Royal College of GPs.    

In an outspoken attack on health secretary Andrew Lansley’s NHS reform plans, she also hit out at his decision to transfer responsibility for rationing access to treatment from the National Institute of Health and Clinical Excellence (Nice) and primary care trusts to GPs in England from 2013.     

“At worst, the negative impact for GPs could be patients lobbying outside their front door, saying, ‘You’ve got a nice BMW car but you will not allow me to have this cytotoxic drug that will give me three more months of life,’”  Gerada told the Guardian in an interview.  

“I’m concerned that my profession, GPs, will be exposed to lobbying by patients, patient groups and the pharma industry to fund or commission their bit of the service. There could be letters from MPs and patient groups, and begging letters from patients.”     

Making GPs “the new rationers” of NHS care could ruin the long-established bonds of trust between them and their patients, undermine “the sacredness of the consultation” and turn patients into little more than “customers” who shop around trying to get the best treatment for their ailment, Gerada added.     

Inherent conflicts of interest in the new system could also jeopardise GP-patient relationships, she warned. “Patients might think that the decision made about their healthcare will be based on self-interest – GPs saving money for themselves rather than spending it on patients.” Certain treatment decisions, and a GP consortium’s need to balance its books “could be misconstrued”.     

The NHS will not survive intact Lansley’s plans to scrap many existing NHS bodies, introduce GP commissioning and push through greater competition between hospitals, she predicted. “I think it is the end of the NHS as we currently know it, which is a national, unified health service, with central policies and central planning, in the way that [Aneurin] Bevan imagined,” said 51-year-old Gerada, who represents Britain’s 40,000 family doctors.     

Lansley’s shakeup will lead to a much greater role for private healthcare companies, the likelihood that England’s health system will look more and more like America’s, and GPs being blamed for things such as the NHS’s inability to cope with a winter crisis, long waiting lists and the decommissioning of services to save money, she added.     

GPs in their new role will bear the brunt of the NHS’s need to save £20bn by 2014, which will lead to far more “postcode lotteries” in services such as IVF, expensive drugs, and even access to particular hospital specialists such as surgeons and gynaecologists.   

Leaving each of the new GP consortiums to decide individually what treatment should or should not be available locally will lead to disputes over access to care.  “I don’t understand why he’s putting in a system that in Scunthorpe you can get a different service to Scarborough, when we’ve spent the last 60 years working against that”, said Gerada. Her comments are the most detailed criticism yet made by any senior doctor of Lansley’s plans, which have caused serious unease among medical organisations.    

John Healey, Labour’s shadow health secretary, used them to portray Lansley as dogmatic and out-of-touch. “These criticisms from an influential GP again reveal how Andrew Lansley is failing to listen to the warnings of doctors, nurses and health experts to slow down on his high-cost, high-risk plans,” said Healey.     

“With plans for the biggest reorganisation in the NHS’s history, it is also becoming clear that he is running a rogue department, operating in isolation from his colleagues in government.” Healey echoed Gerada’s concern about patients in future questioning GPs’ motivations.  “Patients will worry about treatment decisions – are they being taken in their best interest or the best interest of the GP consortium’s budget?”  

The British Medical Association warned the changes could see the NHS fragment. Dr Laurence Buckman, chairman of the BMA’s GPs committee, agreed with some of Gerada’s concerns.  “GPs are fully aware of the difficulties facing the NHS as we enter a very difficult financial period and that tough decisions will have to be taken.   

The BMA has repeatedly expressed its concerns about the timing of the white paper proposals as well as the potential risks and benefits that may result from the government’s plans,” he said.     

Prof Chris Ham, chief executive of the King’s Fund health thinktank, endorsed Gerada’s view that Lansley should move more slowly. “With international evidence this week showing our health system performing well compared to other countries, and the NHS facing significant financial pressures over the next few years, evolutionary change building on existing arrangements offers a more promising route to improving the NHS than radical structural changes,” he said.     

A Department of Health spokeswoman said: “Our reforms will indeed mark a new era for the NHS – one where patients and clinicians are at the heart of the service. Our reforms aren’t an option, they are a necessity in order to sustain and improve our NHS. The reforms are far-reaching but they also build upon existing designs.     

We share a common goal with the RCGP that we all want patients to get the best health and care services.” But she added: “We understand concerns around implementation. That’s why we have consulted extensively on our plans, and have already announced a programme where GP consortia can start testing white paper principles. We will announce the outcome of the consultation later this year. We believe that both purpose and pace are vital to improve services for patients.”

The Ethos & Role of the Physician vis-à-vis Society… by Dr David KL Quek

The Ethos & Role of the Physician vis-à-vis Society…

Dr David KL Quek

MMA News, President's Page, November 2010

This month is proving to be a difficult month for me to write my president’s message. There have been many ongoing developments and undercurrents, which continue to rock the equanimity of the profession and society.

Liberalisation Uncertainties from AFAS

Having now visited Sabah, Sarawak and Melaka for the MIDA-MMA Seminars, I now appreciate more the grave disquiet that is now so pervasive especially among our private sector doctors. The issues of the ASEAN Free Trade Agreements (Mutual Recognition Agreements, MRAs), the changing liberalization strategies, and now the 1Care Health Restructuring plans have become ominous signals for an uncertain future.

With the accelerated approach to liberalisation of health services within ASEAN, more challenges are now forthcoming. If our globalisation gurus and bureaucrats have their way, by 2015, our borders would be fully open, and there will be opportunities for doctors from other ASEAN nations to enter freely into the country to practice once they meet the forced modified requirements of our national regulatory bodies. Of course we would also be free to expand beyond our shores. Competition and free flow of services and goods will be the order of the day.

With our growing number of doctors and medical graduates, it is not inconceivable that we would have a severe glut and highly competitive atmosphere, which would threaten the position and livelihood of medical professionals in the country. We have to ask the wisdom of our rapidly growing doctor numbers in this globalised scenario from the perspective of the medical person, and not simply bureaucratic number-crunching. How this liberalisation especially for the private sector will pan out remains to be seen especially with our purported plans to integrate the public-private sector…

The Private Sector Malaise…

Our earlier GP Summit continues to rankle many among those who have participated as to where we are heading, after this exercise. Some of our members have lamented the fact that the GP issues appear to have subsided in interests and enthusiasm.

The primary care coalition is struggling to come up with an adequate and cohesive approach to coming out with a united collective consensus statement or document that is agreeable or consistently acceptable to every disparate group. There remain deep dissensions and emphases of which approach to take. We’re resolving this even as I now write, but sustained commitment is often a hollow if trying experience and I suspect many of us well-intentioned leaders are suffering from some form of lacklustre burnout… Perhaps, it is just me…

But we have let the authorities know that there have been loud rumblings from the ground, and we have been disclosing to the policy makers, some serious points of contention and concern. To be fair, there has been some modification of views and emphases on the part of the MOH and authorities, which now recognize more sympathetically, that some of our grouses and disquiet have merits, while allaying our so-called misconceptions.

The DG of Health has personally written a clarification piece in the October 2010 MMA News, to explain in greater detail the rationale for reform, and what the changes are all about, while at the same time reassuring the GPs that they would not be marginalized—that they would all be incorporated into the larger scheme of things.

But rightfully, DG has re-emphasised that GPs must continually upgrade their knowledge and skills—what is unclear are the minimum requirements or expectation or even the newer regulatory framework that the MOH is alluding to for the near future. Therefore, if anything, the future promises to be more rife with greater and greater oversight and perhaps even more intrusive expectations.

We agree that all of our services in the healthcare must be improved as we move in tandem with modern times and expectations, but knowing our extremely spotty and poor healthcare database or its accuracy or inadequacy, we worry that the true picture might not emerge.

We need more systematic, regular research and ongoing studies on the entire system of health care, the private as well as the public. We need to determine how these can be utilized as reliable focus points and be transparently translated into practical improvements, based on accurate and testable hypotheses and findings.

For example, we need to be able to show that certain sectors have shown inadequate performance outcomes, and failures, but these must be neutrally obtained with the view on how to improve systems. For example, do we have reliable data that some GP clusters or soloists have been poor in maintaining BP goals or diabetic HbA1c levels? Have we data to conclusively identify complication rates which increase hospitalisations or worse, adverse outcome results such as death or amputations, etc?

If so, are they testable and fairly documented? If not, how can we implement incentives or disincentives for such presumed performance outcomes? Do we have an agreed set of parameters, which can be adopted and tracked (preferably via online mechanisms) so that these are easily apparent and cannot be frivolously challenged; or so that supervising authorities are not accused of selective prosecution or discrimination? This is critically important because, people’s livelihoods are going to be affected.

Perhaps, I internalise too much, and feel too much…

Professional Fees Revision, at last?

It is now more than 4 months after the DG of Health and the MOH called a meeting to reconsider a timely revision of the professional fees for medical practitioners in the country, i.e. a revision of the 13^th Schedule. Some 160 physicians turned up in this epic assembly at Putrajaya, which clearly showed that doctors are concerned when their bottom lines are at stake. Since then there have been several meetings, sometimes every 2 to 3 weeks.

Having said that, our meetings have not been smooth sailing. The various committees and task force for the MOH fees revision for medical practitioners have been mired in contentious parochial interests, with many societies actively demanding that the MMA takes a back seat, even despite the fact that we have been instrumental in initiating, moderating and revising our medical professional fees these past 20 years or so. But history and memories are short, and not often appreciated these days… Perhaps MMA’s role is over, if we believe the main detractors who demand for their greater say and input…

It appears that all our hard work has come to naught (our 5^th schedule after some 5 years’ work, were rejected outright due to prejudice and misinformation, more than substance) because others supposedly more intelligent and more studied than us, have allegedly better versions of how to improve the fee schedule.

I would be remiss if I do not argue that most of these new proclamations are noted for their self-interests, and that these discordant if big changes would have resulted in possible public outrage, if fully accepted or implemented, without modification or greater moderation or with a community spirit of give and take.

Each and every college and/or society of medical/surgical specialty/subspecialty are aggressively presenting their cases for the highest ‘most’ appropriate fees for their own perceived weightage and skills. In other words, nearly everyone believed their own specialties are the best, the hardest to learn and practice, the most skilled, the most risky, the most medico-legally costly, and thus deserving of the highest relative value scales. More and more are urging changes in the fee codes and bands, which shift these to the highest level of reimbursement, tolerated by the committee or task force.

Such internecine infighting for our own narrow vested interests, unfortunately, will not augur well for what the authorities will accept or worse for what the public and/or the healthcare buyers or payers will recognize or accept. We simply just cannot afford a free-for-all upward fee revision, which is not based on some form of ethical anchor, of moderation or levelheaded comparisons or relative benchmarking with other professions or other jurisdictions such as those so established in either the USA or Australia.

Of course the free market system is useful for determining changing values and costs, but these should not be dictated by a unilateral presumption on the part of one party alone, i.e. by medical doctors, without due consideration of our social duties, responsibilities and our unwritten compact with our patients and the public on the other side of the equation…

There appears to be a rushed if mad scramble of trying to gain the most for each of the multifarious disciplines, which I fear will undermine the feasibility of real changes and modifications for the fees, which have remained stagnant for the past 10 years or so.

The current schedule now enshrined in the PHCFS regulations is almost entirely based on the MMA 4^th schedule of 2002 (which version was initiated since 2000!). Once listed as part of the regulations however, it is extremely difficult to modify, which is why the MMA has been stridently seeking its delinking from the Act and Regulations. We are happy to note that the MOH is rethinking this aspect to enable a fairer system of reimbursement strategies. We do need more frequent and regular revisions of this very dynamic schedule of fees if we are to be fair to the medical practitioner and our changing inflation index.

Still, I wish the MOH, now acting as moderator, all the very best to come up with something more timely, more wholesome and acceptable to the Malaysian public, and certainly not just for a few or even the majority of medical doctors… we are still dependent on our patients, who are our raisons d’être, lest we have forgotten…

Medico-legal Reminders

Recently, I was preparing for a talk for the Medico-Legal Conference, when I found a few catchphrases, which recurred over and over again. One of these is the concept of “truth-telling” and veracity and the physician. It became the most meaningful phrase which exhorts the Physician to an ethical standard far beyond the norm.

“Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.

“In their day-to-day practice, doctors are committed to:

o   integrity

o   compassion

o   altruism

o   continuous improvement

o   excellence

o   working in partnership with members of the wider healthcare team.

“These values, which underpin the science and practice of medicine, form the basis for a moral contract between the medical profession and society. Each party has a duty to work to strengthen the system of healthcare on which our collective human dignity depends.” (RCP 2005)[1]

Informed consent must be more fully recognized as standard operating procedure and careful documentation and patient family rapport a must, if we were to see a containment of more medicolegal challenges in the foreseeable future. But as more and more of our people are becoming more knowledge savvy, the information gap or asymmetry would drastically decrease, so we cannot afford to remain the aloof paternalistic doctor as before—we have to communicate more and become more caring and empathetic.

Forensic Disquiet

In this regard, our medical professionalism must also extend beyond the usual remit of the clinical medical professional.

Of late, the forensic actions of some of our medical colleagues leave much to be desired. Forensic professionals especially medical experts must exercise due restraint from political or other pressures, which can seriously undermine their roles and responsibilities. It is to be emphasised that as forensic experts, their duty is to the ultimate testable truth and not to be colored by prejudices or other influences (State or police), which determines in many cases, the risk of harm or punishment for the innocent or the guilty.

For the dead, that duty is even higher, when truth-telling must be fearless and impartial so that closure and justice can be obtained by the aggrieved and their loved ones.

It is now recognized that forensic ethics-related problems have remained largely unexamined, but deserved the closest scrutiny. These included testifying with certainty but with uncertain knowledge; the temptations, conscious or unconscious, of harming or helping forensic evaluees; and over-identification with the side that hires. It is crucial that the forensic expert be scrupulously honest and be recognized as one with impeccable integrity.

It is true that few forensic professionals can escape acting as a double agent because he could not combine the traditional goal of beneficence with the simultaneous task of trying to serve the interests of justice. But he or she must adhere to whatever is testable to be true and not be biased. Thus, in many ways, the ethics of forensic science are in chaos.

I’d like to end by quoting the following, on the Code of Chivalry and Ethics of Forensic Science, as food for thought:

“The pledge: To protect the innocent from wrongful conviction, to help convict the guilty. The fulfillment of this two-fold promise requires assurance of professional competence across all disciplines, and enforcement of rigorous ethical standards.” ~ Kathy Reichs[2]

“(T)wo broad principles that govern the ethics of forensic work: truth-telling and respect for persons. In regard to truth-telling, I was referring to a two-fold obligation, beginning with the duty of subjective truth-telling or honesty. That is, forensic psychiatrists should testify to what they believe to be true, regardless of whether such testimony favors or disadvantages the parties employing them… Thus, truth-telling must encompass an additional obligation of being objectively truthful. Testimony, whether written or oral—at trial, deposition, or in another venue—should accurately reflect the scientific data on the subject at hand and the consensus of the field. When the testifying expert goes beyond the data or controverts generally accepted professional understandings, that deviation should be made clear… Assuming we circumscribe our role so as to comport with this ethics framework, we can legitimately offer useful information to the courts. Our insights will not, in themselves, resolve legal or moral dilemmas; but they should provide the factual background and interpretive context to allow legal decision-makers to make better choices than they would, left unaided. A modest role, perhaps, but not one to be scorned.” ~ Paul S. Appelbaum[3]

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[1] Royal College of Physicians (2005). Doctors in Society: Medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP.

[2] Kathy Reichs in “Camelot? Or Scam a Lot?” in 206 Bones, Pocket Books, New York, 2009

[3] Paul S. Appelbaum, MD in “Ethics and Forensic Psychiatry: Translating Principles Into Practice”, J Am Acad Psychiatry Law 2008; 36:195–200